Guarantor: You must complete the Applicant section about yourself and the Co-Applicant section about your spouse if you reside in a community property state.

Type of credit you are applying for:

New Card ApplicationCredit Limit Increase

Limit Requested: $

Applicant - Personal Information

Account Number

Last Name

First Name

M.I.

Are you a member of Heartland Credit Union?

YesNo

SSN

Email

Birthdate (00/00/00)

Home Phone

Cell Phone

Status

Monthly Payment $

() -Second partThird part

() -Second partThird part

OwnRentOther

Address

City

State

Zip

How Long At This Address?

Marital Status

SingleMarriedSeparatedDivorcedWidowed

Mailing Address (if different from above)

City

State

Zip

Employer

Self Employed

Work Phone

Date Employed

YesNo

() -Second partThird part

Employer Address

Position/Occupation

Monthly Gross Income $

Source of Additional Income: Income from alimony, child support or separate maintenance need not be revealed if it is not to be considered in determining creditworthiness

Amount Per Month $

Co-Applicant - Personal Information

Account Number

Last Name

First Name

M.I.

SSN

Email

Birthdate (00/00/00)

Home Phone

Cell Phone

Status

Monthly Payment

() -Second partThird part

() -Second partThird part

OwnRentOther

Address

City

State

Zip

How Long At This Address?

Marital Status

SingleMarriedSeparatedDivorcedWidowed

Mailing Address (if different from above)

City

State

Zip

Employer

Self Employed

Work Phone

Date Employed

YesNo

() -Second partThird part

Employer Address

Position/Occupation

Monthly Gross Income $

Source of Additional Income: Income from alimony, child support or separate maintenance need not be revealed if it is not to be considered in determining creditworthiness

Amount Per Month $

Balance Transfer

Please transfer the following balances from other credit cards to my Heartland MasterCard Credit Card

Please note: The payoff check(s) will be mailed to you, so you can send it to the other creditor(s) for proper credit to your account.

Card One

Amount $

Account #

Credit Card Issuer/Creditor Name

Payment Address

City

State

Zip

Card Two

Amount $

Account #

Credit Card Issuer/Creditor Name

Payment Address

City

State

Zip

Credit Card Disclosure Table

Gold MasterCard

Annual Percentage Rate (APR) for Purchases

8.25%*

Cash Advance APR

8.25%

Balance Transfer APR

8.25%

Grace Period

28 Days

Method of Computing the Balance for Purchases

Average Daily Balance
(including new purchases)

Annual Fee

n/a

Variable Rate Information

Your APR may vary. The rate is determined by adding: 5% for purchases, 5% for cash advances, and 5% for balance transfers to the Prime Rate published in the Wall Street Journal. Rate based on credit worthiness, subject to approval.

Additional Fees

Transaction Fee for Purchases

None

Balance Transfer Fee

None

Late Payment Fee

$25.00***

Over-the-Credit Limit Fee

$0.00

Returned Check Fee

$25.00

Card Replacement Fee

$5.00

Additional Fees *The Prime Rate used to determine your APR is the rate published in the “Money Rates” table of The Wall Street Journal on the statement cycle date of each month.

***if five (5) or more days late

The information about the costs of the card described in this application is accurate as of 2/2012. This information may have changed after that date. To find out what may have changed, contact the credit union.

OHIO RESIDENTS ONLY: The Ohio laws against discrimination require that all creditors make credit equally available to all creditworthy customers, that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law.

WISCONSIN RESIDENTS ONLY: (1) No provision of any marital property agreement, unilateral statement under Section 766.59, or Court decree under Section 766.70 will adversely affect the rights of the Credit Union unless the Credit Union is furnished a copy of the agreement, statement or decree, or has actual knowledge of its terms, before the credit is granted or the account is opened. (2) Please sign if you are not applying for this account or loan with your spouse. The credit being applied for, if granted, will be incurred in the interest of the marriage or family of the undersigned.

Please Read the Following Carefully Before Submitting: You promise that everything you have stated in this application is correct to the best of your knowledge. If there are any important changes you will notify us in writing immediately. You authorize the Credit Union to obtain credit reports in connection with this application for credit and for any update, increase, renewal, extension, or collection of the credit received. You understand that the Credit Union will rely on the information in this application and your credit report to make its decision. If you request the Credit Union will tell you the name and address of any credit bureau from which it received a credit report on you. It is a federal crime to willfully and deliberately provide incomplete or incorrect information on loan applications made to federal credit unions or state chartered credit unions insured by NCUA. You understand that the use of your card will constitute acknowledgment of receipt and agreement to the terms of the credit card agreement.

A condition of your account is your granting us a security interest in your share accounts. By submitting below you grant us a security interest in all individual and joint share and/or deposit accounts you have with us now and in the future to secure your credit card account. Shares and deposits in an individual Retirement Account and any other account that would lose special tax treatment under state or federal law if given as security are not subject to this security interest. When you are in default we may apply the balance in these accounts to any amounts due under the credit card agreement.

What is the best way for us to contact you?

Prior to submitting this application, please enter the security code in the box below